Sometimes

The needle slid through her chest with a snap.

Her grandmother on her knees in the back corner, a murmured prayer filling the room.

And despite all our hope and desperation, nothing came back. Not air, not blood. The four people it took to hold her down all looked at me, a sick expression on each of their faces. Nothing on the right. Might as well try the left. I grabbed a fresh 21 gauge, hooked up to short IV tubing with a plastic clamp, and connected the end to a 10cc syringe. I found my spot: second intercostal space, mid-clavicular line. My finger jabbed each rib. Paranoid, I counted, recounted, verified the spot three times. Then I asked for a confirmation from a bystander. Then I rechecked. I felt nauseous. I felt anything but steady. I couldn't believe I was in the same shit again: another newly-diagnosed-HIV-positive-four-year-old-girl-with-impending-respiratory-failure. It's been a month of working in Queen II. A month of working in the most feared hospital in Lesotho. A month of trying to turn that reputation around.

The second needle went in as easily as the first. Nothing. I pushed the inch and a half needle all the way to the hub. Nothing. Not air, not blood, just a dead end. It wasn't a pneumothorax that was killing her. It wasn't a collapsed lung that was sucking the life out of her, causing her chest to cave in. The routine hardly ever changes here. They come in sick, they get sicker, we get desperate, we start stepping up care, and then we show up the next morning and absolution has come and gone.

But it was my last day, and when you’ve come to the conclusion that you really have nothing, absolutely nothing to lose, you start doing crazy things. I had never done one of these. I hadn’t ever seen one of these. It’s a pretty straightforward procedure done when there is the slightest suspicion of a collapsed lung, it doesn’t even require an XRay. The only difference in our case was that it wasn’t really clinically indicated. She didn’t have the requisite shifting of her trachea, the distension of her neck veins, the differential breath sounds between the two sides of her lungs. What she did have was a complete absence of any air moving through her lung fields, and she was getting dramatically worse in front of our eyes. Same song, second verse.

I looked at the other PAC doctor who was transitioning to take over the wards for a couple weeks in my absence; neither of us was entirely ready for this. But then, we had just spent the last twenty minutes resuscitating a child in the next bed. We had pulled her back from the brink, regained a heart rate, but she never started breathing on her own. And in the end, we bagged her, gave her breaths through a mask hooked up to a rubber balloon, until we could no longer hear her heartbeat. It’s gut-wrenching to try your hardest to bring a child back, to stabilize them, only to realize that at the moment when fates can change, you don’t have the what it takes to make the next step.

The only advice I got from the Dr. Phiri, the veteran doc looking on as we worked on her patient was: next time you do that, make sure tell all of the mothers to leave the room.

So when we walked back into acute room, our plan resolved, equipment in our hands, I took a look at the single nurse in the room.

“ I need every mother out of the room except the one for that child.”

The nurse translated, the mothers looked at each other, and then each one filed out. The mother for my child wasn’t even in the room, she was outside on the bench in tears, denying the obvious. It’s a bad sign when you’re child’s doctors are visibly scared.

After bringing her to the bedside, I tried to explain stepwise what we were about to do.

The reason – her child was very sick and we didn’t know why

The risk – if she didn’t have a collapsed lung, we could inadvertently introduce air into a vacuum cavity, thereby actually causing a collapsed lung. And if our aim was poor and we hit a major vascular structure, there would be bleeding – unholy amounts of blood.

The alternatives – none

The benefits – immediate improvement, comfortable breathing, re-expansion of her lung. But here was the rub, putting a needle in someone’s chest was only a temporary measure, it must be followed with a more permanent chest tube hooked up to a vacuum if in fact the lung in collapsed. I had neither the equipment for a chest tube, nor an available surgeon to assist me. DIY medicine only gets you so far if you don’t have training, equipment, or backup.

So as I stood there, planting the needle in her chest, watching for air or blood to come back into the syringe, I was secretly relieved that we had the wrong diagnosis.

With little else left that we could do, and driven by a mixture of desperation and bravado and the feeling that we had already gone this far, I wheeled a cart into the room and secured her 80lbs steel oxygen tank to the rails. Jill, the other PAC doc scooped her into her arms, and with grandmother and our translator in tow, we bolted for XRay, a ten minute walk to the opposite side of the medical campus, in an entirely different building. Because of its distance and our patient’s dependence on oxygen, getting an XRay was more dangerous than blindy putting needles into her chest.

Our group of four plus one sick child and weighted cart rattled over stone and pavement, through dirt and finally into the wards. As we sat her down on the xray table, her mouth opened wide, her eyes tearing, but not a sound came out. Something had stolen her breath, her voice, and hardly a whisper left her lips where there should have been a wail. There’s a condition described in the medical literature as “a look of impending doom.” I’ve seen it a dozen times this month, and each time, it has lived up to exactly its name. Bad things happen soon afterwards. Jill and I both recognized it as she sat there on the table. Everyone else in the room standing ten feet away from her as the XRay machine uttered a high pitch squeal, a click, and then fell to a hum.

Half an hour later, she was back in her bed, mother at the bedside, and we had an xray in hand. All of that effort - and the results: bilateral perihilar opacities. It told us nothing. We had come no closer to a solution, and I think it was at this point that I just gave in. When you’ve done everything, when you’ve thrown every antibiotic in your arsenal, when you’ve gone on a limb and done not one but two things against your better judgement and still nothing has changed, you know its time to start letting nature run its course. Sometimes it’s not about what we can and can’t do. Sometimes, despite everything, what our patients need most is time/luck/prayer. And sometimes, miracles happen.

Sometimes, they make it through the weekend.

I called Jill this morning to check on her. She was still alive, slightly more comfortable, still on oxygen. She had stabilized. I have no idea how she got there. I’m not sure what in the long list of things we did actually helped her, but something did. And for me, that’s enough. It’s enough to reaffirm all of this effort. It’s enough to make me take that next step, to use that desperation to push further, to fight harder for every single patient. The fact that three children left the acute room last week, escaped the hospital in better health than when they came in is all the encouragement I need to keep going. And even now, as things are starting to wrap up and I’m preparing for a short trip home, I am looking forward to coming back. The tone has changed. Nurses are working harder, the medical officers are engaged, and the staff is taking note. To borrow a term - there is a renewed sense of urgency.

Throughout Lesotho, the country's national referral hospital is regarded as a place to die. I'm making it my mission to change that sentiment.